Improving home-like environments in long-term care units: an exploratory mixed-method study

Although the number of older adults requiring care is rapidly increasing, nursing homes have long faced issues such as the absence of a home-like environment. This exploratory mixed-method study investigated how residents (n = 15) in a long-term care unit in South Korea perceive home-like features and privacy in their living spaces. The results indicated that most participants were satisfied with the homeliness and privacy of their environment, but some were unhappy with the level of privacy. Most participants had low scores on the Geriatric Depression Scale and the Pittsburgh Sleep Quality Index, indicating low levels of depression and sleep disorders. Sleep quality was affected by factors such as sensory environment, staff visits, and room temperature. Although participants appreciated social support and private rooms, they expressed a desire for larger rooms. Overall, this study provides preliminary insights into older adults’ views on their living spaces in long-term care with implications for improving their quality of life.


Participants
Facility staff screened volunteers to ensure they could communicate effectively and were free of cognitive disorders in addition to having resided in the facility for at least six months.Of 80 participants, 15 participants were interviewed (see Table 1).Most participants were women (n = 11, 73%), with an average age of 87.2 years.Of these, eight participants had roommates in double-occupancy rooms, whereas seven lived in a private rooms.
The decision regarding the sample size for this study was influenced by practical considerations and the nature of the research context.Given the limited pool of eligible participants within one single LTCU where the study was conducted, the sample size was determined by the number of individuals who met the inclusion criteria and expressed willingness to participate.No formal power analysis was performed; however, the sample size of 15 participants was deemed appropriate to capture a diverse range of experiences and perspectives within the study population.Although efforts were made to ensure data saturation through iterative data collection and analysis, the small sample size may limit the generalizability of the findings, particularly in the context of a triangulation design.It is important to acknowledge these limitations and interpret the results within this context.

Procedure and measurements
The research team tried to establish a comfortable environment for the participants and started with informal conversations to build rapport prior to the interviews.The interviews were conducted in residents' rooms and enclosed spaces for privacy.The interview questions used straightforward and non-technical language to facilitate a better understanding for older adult participants to aid in answering the questions.The questions were reviewed by the staff members.Additionally, the interviews were conducted at a pace that allowed participants to proceed and respond comfortably.
The interview began by gathering demographic data, including participants' gender and age.It focused on four key areas: mood, sleep quality, home-like features, and privacy.To assess mood and sleep quality, we used the translated Geriatric Depression Scale (GDS) short form, consisting of 15 questions, and the translated Pittsburgh Sleep Quality Index (PSQI), respectively.The GDS short version comprises 15 yes/no questions designed for older adults.A score ranging from 0 to 5 indicates no presence of depression, that from 5 to 10 suggests mild depression, and a score from 10 to 15 indicates severe depression 23 .The inventory has good reliability (r = 0.85), and a high level of validity, ranging from 0.83 to 0.84 24 .The PSQI is developed to measure sleep quality, including duration of sleep, wake patterns, sleep-related problems, and so on 25 .The PSQI, being the most commonly www.nature.com/scientificreports/utilized assessment tool for sleep quality, has been translated into 48 languages, making it widely accessible 25 .
The PSQI has a high internal consistency (r = 0.83) as well as a high test-retest reliability 26 .
Although the GDS and PSQI are written measurements, we verbally administered the questions.Given the participants' average age, they might struggle to read, understand, and answer the questions; thus, the research team verbally asked the questions and gave further explanations if needed.We also explored participants' perceptions of home-like features and privacy in their living spaces.Satisfaction with these aspects was measured using a series of questions for each theme, rated on a five-point Likert scale.In addition to the semi-structured interviews, which served as the primary data collection method, the study employed triangulation to gain deeper insights into participants' views.Triangulation involves the use of multiple data sources, methods, or researchers to corroborate findings and ensure a comprehensive understanding of the research phenomenon.In this study, triangulation was achieved by incorporating both qualitative and quantitative data collection methods, as well as involving multiple researchers in the data analysis process.The qualitative data obtained from the interviews provided rich insights into participants' perspectives, whereas quantitative measures such as the GDS and PSQI offered complementary information on mood, sleep quality, and other relevant factors.By triangulating data from different sources and methods, the study aimed to strengthen the credibility and robustness of the findings, thereby enhancing the overall trustworthiness of the research outcomes.Additionally, we included open-ended questions about home-like features and overall privacy, including visual and acoustic privacy (see Table 2).

Ethical approval
This study was approved by the university institutional review board (IRB) of Kyung Hee University [KHSIRB- 22-160].Participants provided verbal consent to participate in the study after being read a consent form, as approved by the IRB.The interviews were conducted in person and lasted between 30 and 45 min.The

Data analysis
The recorded interviews were transcribed using the services of a dedicated company specializing in transcription.
Qualitative data analysis was conducted using thematic analysis, a method commonly employed in qualitative research to identify patterns and themes within the data.Two independent researchers performed the analysis manually, initially familiarizing themselves with the data to develop preliminary themes based on the theory of supportive design 27 .The theory of supportive design focuses on creating environments that support the physical, emotional, and social well-being of individuals.These themes were refined through iterative reviews and discussions to ensure comprehensive data coverage.While a formal codebook was not developed, the researchers independently coded the responses into primary and secondary themes using Microsoft Excel.This process facilitated the identification of central themes and patterns within the data.To enhance the reliability of the coding process, the researchers compared their coding and resolved any discrepancies through consensus.The inter-rater reliability was calculated as the ratio of agreements between two independent researchers, indicating the level of consistency in their coding or data.The inter-rater reliability coefficient for this process was calculated to be 0.92, indicating a high level of agreement between the researchers.While qualitative software tools were not utilized in this study, the manual approach enabled a thorough and systematic analysis of the data.

Results
Table 3 summarizes the quantitative data.Of a possible 15 points, most participants had low scores, ranging from 2 to 7, regarding their mood.Only two participants (P2 and P3) received a score of seven.The maximum score for sleep quality was 24 points, with higher scores indicating poorer sleep quality.Participant P3 scored the highest with 21 points, whereas P4 had the lowest score of 0 points.The average satisfaction scores for the home-like atmosphere and privacy conditions suggest that most participants were content with these aspects.However, participants P2 and P3 expressed extreme dissatisfaction with their level of privacy.

Quality of sleep
The open-ended question responses highlighted specific factors affecting participants' sleep quality beyond their PSQI scores (see Table 3).Those with scores above 12 perceived their sleep as poor.Two participants (P5 and P8) reported poor sleep despite having moderate PSQI scores.

Sleep disruptors
Participants identified various factors affecting their sleep quality, with noise, light, and temperature being the most cited disruptors (see Table 4).Comments regarding noise disturbances were frequent, with 7 of 15 participants mentioning noise from hallway traffic, staff activities, or other residents as interfering with their ability to sleep.Light disturbances were also prevalent, with three participants commenting on the brightness of nighttime health checks or hallway lighting disrupting their rest.Temperature discomfort was noted by two participants, particularly regarding overheated rooms affecting their ability to sleep.P3 mentioned that she was unable to adjust her blanket to cool down because of her health condition.Three older adults expressed feelings of anxiety or discomfort related to their living environment or personal health issues, which affected their ability to fall or stay asleep.

Social support and physical environments
Most participants expressed satisfaction with the social support provided by staff and family members within the LTCU (see Table 5).Seven participants felt that the staff 's care, especially when they were unwell or uncomfortable, contributed to a homely atmosphere.Two others valued the opportunity to spend time with family within the facility.Regarding physical environments, the living space design was the second key satisfaction factor, with five participants appreciating the private rooms and distinct areas for the dining room, living room, and bedroom.There are two common living rooms, one in each wing (see Figs. 1 and 2).These living rooms can be directly accessed from all bedrooms.In essence, the living room is positioned at the center of the space.www.nature.com/scientificreports/Therefore, when residents exit their bedrooms, they enter the common living room, similar to the layout of a typical house.In addition, the living rooms were designed to create a comfortable and cozy feeling (see Fig. 4).Finally, three participants attributed their sense of home to the facility's offerings, such as homemade meals and rehabilitation services.However, some participants were dissatisfied with social support and physical environments.For example, three participants (P7, P8, and P15) wanted to forge stronger connections with their neighbors.Two participants (P6 and P12) felt that their autonomy was restricted by living in shared spaces.Last, because of the emotional toll of witnessing others in varying health stages, participants advocated for the segregation of residents based on health conditions, seeking living arrangements that cater to individual needs and health statuses.

Desires for personal space
Several participants expressed dissatisfaction with the home-like features, providing specific reasons for their discontent.Despite high satisfaction scores on the five-point Likert scale (Table 3), many participants offered suggestions for improvements when prompted about enhancing their home-like environments.Eight participants wanted to enlarge their physical spaces, with P4 appreciating the efficient organization of furniture in his compact room but still wishing for more space.All the necessary elements for living are included in the residents' rooms, but the area is not spacious, especially for double rooms (see Fig. 5 which shows an unoccupied double room).P6, who has a roommate, said she wished to have her own private space because she could not even play the radio without fear of disturbing her roommate.The absence of televisions (TVs) in the shared rooms led to a common request for personal TVs and clocks.

Privacy
Acoustic and visual privacy Generally, the participants were satisfied with their privacy conditions (see Table 6).They particularly appreciated the physical aspects of acoustic privacy, such as soundproof doors and walls, which they found highly effective.
The floor is made of wood and is effective in soundproofing (see Fig. 6).Participants noted that when the door was closed, noise was significantly reduced.Regarding visual privacy, the design of the space included areas not visible from the hallway, and the combination of a door and curtain provided additional visual privacy.

Acceptable privacy level
The five-point Likert scale revealed that certain participants were not satisfied with their acoustic and visual privacy.However, when prompted with open-ended questions about potential improvements, most participants did not provide detailed responses.Rather, they expressed that the privacy conditions provided by the facility were acceptable.Additionally, one participant (P6) said that a certain level of noise was acceptable because complete silence can cause anxiety in people, who are inherently social beings.

Discussion
Overall, the findings of this study offer exploratory insights into enhancing the quality of life for residents in assisted living facilities.The results suggest that environmental design enhancements, such as lowering noise levels, offering more spacious personal rooms, and accommodating individual privacy needs, could improve sleep quality and boost resident satisfaction.The results offer preliminary insights into sleep quality, homeliness, and privacy in assisted living facilities in South Korea.The data indicates that some residents suffer from poor sleep quality because of sensory disruptions, such as noise, light, and room temperature.This aligns with prior studies that identified the sensory environment as a crucial element in sleep disruption.For example, one study found that noise and light frequently affect the   28 .Regarding clinical implications, nursing staff can use this information to implement strategies aimed at minimizing these disruptions.For example, they can ensure that nighttime health checks are conducted as discreetly as possible to avoid disturbing residents' sleep.Additionally, they can regulate room temperatures to maintain a comfortable sleeping environment for residents.However, this study also highlights the distinct challenges encountered by individuals with health conditions residing in residential care.For example, regular health checks by staff, which often involve turning on lights, can disrupt their sleep.Beyond environmental factors, this study pinpointed the presence of staff, uncomfortable bedding, and anxiety as factors that may contribute to subpar sleep quality.These insights align with previous research showing that social and psychological elements affect sleep quality 29 and stress levels 30 .
Concerning home-like environments, most participants were satisfied with the home-like environment features of the facility, with social support from staff and family, private rooms, and quality services.However, some participants were dissatisfied, recommending enhancements such as larger private rooms, increased personal space, improved neighborhood relations, and health condition-based resident separation.
The current findings, compared with previous literature, confirm the significance of social support from staff and loved ones in creating a home-like environment 31 .These results highlight the importance of staff training and fostering social interactions between residents and staff to strengthen residents'' sense of belonging and connection within the facility.This study highlights the importance of creating a home-like atmosphere within long-term care facilities to promote residents' well-being.Nursing staff can play a crucial role in fostering such environments by providing social support and personalized care to residents.They can engage residents in activities that evoke feelings of home, such as decorating their living spaces with personal items and organizing   www.nature.com/scientificreports/family visits.Moreover, staff can advocate for improvements in facility design, such as offering larger rooms and incorporating elements that resemble home furnishings.Furthermore, "our finding that private rooms increase residents'' satisfaction align with those of previous research 32,33 .Private rooms provide a sense of independence, control, and privacy, which can enhance well-being and quality of life.Therefore, long-term care facilities should consider offering private rooms to enhance residents' satisfaction with their living environments.
The current study's findings highlight the necessity for larger rooms, personal spaces, and improved neighborhood relations, echoing prior research 4 .These improvements can bolster residents' sense of comfort, safety, and social connectedness, which are vital for a home-like environment.Moreover, this study confirms the significance of segregating residents by health condition, a practice supported by earlier studies emphasizing the need for personalized care 34 .Such segregation can improve residents' quality of life, mitigate negative emotions, and increase satisfaction with their living environment.
Privacy is essential for quality care in long-term care facilities 4 .It involves an individual's control over their personal information and the option to be alone when needed.The physical environment in long-term care facilities significantly affects residents' privacy.Thus, participants were satisfied with their acoustic and visual privacy, likely because of effective soundproofing, strategic spatial layout, and the privacy features offered by the facility.While single rooms provide more privacy, two of the related challenges are loneliness and social isolation.To address this concern, long-term care facilities must proactively implement strategies to foster social connectedness and mitigate the risk of isolation among residents.While transitioning to more spacious or shared living arrangements may be a long-term solution, immediate steps can be taken to enhance social interaction within existing facilities.This may include organizing group activities, establishing community spaces for communal gatherings, facilitating peer support programs, and encouraging meaningful engagement between residents and staff.Additionally, leveraging technology and innovative communication platforms can provide opportunities for residents to stay connected with their loved ones and the broader community, thereby reducing feelings of loneliness and isolation.
However, notably, some participants expressed dissatisfaction with their privacy conditions, even though the overall satisfaction scores were high.This aligns with past research indicating that certain long-term care residents are dissatisfied with their privacy 35 .Specifically, dissatisfaction has been noted with shared bedrooms, the absence of privacy curtains, and poor sound insulation.According to Burack et al. 35 , participants expressed a desire for greater privacy and control over their living arrangements.They reported feeling uncomfortable with having a roommate and often felt they had no choice.Participants also expressed concerns about the staff entering their rooms without knocking or respecting their privacy.Similarly, in the present study, some participants wished for larger rooms, TVs in shared rooms, and improved soundproofing.Additionally, this study revealed that while most participants were satisfied with their privacy conditions, some expressed dissatisfaction and desired enhancements.Nursing staff can address these concerns by respecting residents' privacy preferences and ensuring that their personal space is adequately protected.Staff should knock before entering residents' rooms and provide them with the option to control their environment, such as adjusting curtains for visual privacy.Moreover, facilities can consider implementing measures to reduce noise levels and enhance soundproofing to further protect residents' privacy.
Some participants in this study were unaffected by noise, potentially influencing their satisfaction with acoustic privacy.This finding highlights the importance of individual differences in privacy perception within longterm care facilities.This study suggests that although the physical environment is crucial for ensuring privacy, personal factors such as hearing impairment and social requirements are also key in shaping privacy perceptions.
Finally, this study is especially significant for societies with rapidly aging populations, such as South Korea.South Korea's population in 2070 is expected to decrease by 27% compared with 2020, and the population aged 65 or older is expected to increase from 17.5 to 46.4% 36 .In response to one of the highest aging rates in the world, the number of long-term care facilities continues to increase.Hence, based on the results of this study, it is important to provide LTCUs that can improve the quality of life of older adults through a home-like environment.

Limitations
The findings of this study should be interpreted with caution owing to several inherent limitations.First, the sample size, consisting of only 15 participants, raises concerns about the generalizability of the results to the broader population of older adults in LTCUs.The limited participant pool may not adequately represent the diversity and variability within this demographic, making it challenging to draw universally applicable conclusions.To enhance the robustness of future investigations, it is imperative to conduct studies with more extensive and more diverse samples.
Moreover, the 'study's exclusive focus on a single LTCU in Seoul, South Korea, introduces geographical and contextual limitations.The characteristics and experiences of older adults in this particular LTCU may not be representative of those in different regions or countries, emphasizing the need for multi-site studies to capture a more comprehensive understanding of the subject matter.
A notable concern is the potential for self-selection bias, as participants were chosen based on their willingness to participate, even after being screened for health conditions and length of residence.This could introduce a bias towards individuals who are more inclined to engage in research activities, potentially skewing the results and limiting the generalizability of the findings to the broader population of older adults in LTCUs.
The following limitation of the study pertains to the sample selection process, which relied on screening by facility staff to exclude participants with cognitive issues.This approach may not have been adequate to accurately assess participants' cognitive statuses, as it lacked formal inclusion/exclusion criteria specifically designed to evaluate cognitive functioning.Consequently, there is a possibility that individuals with mild cognitive impairments or undiagnosed cognitive issues may have been included in the study sample.Additionally, it is important to acknowledge that the study's findings may be more relevant to cognitively intact assisted living residents rather than the entire resident population of long-term care facilities.This limitation suggests that the results may not fully capture the experiences and perspectives of residents with cognitive impairments, who may face unique challenges and have different care needs.Therefore, future research should consider implementing more rigorous methods for assessing cognitive status and ensure that the sample is representative of the broader population of residents in long-term care facilities.
Additionally, another limitation of this study is the absence of data collection regarding participants' health statuses and frailty.This omission limits the depth of understanding regarding how residents' health conditions may influence their perceptions of home-like features and privacy in long-term care settings.Future research could address this limitation by incorporating measures of health status and frailty into data collection procedures, allowing for a more comprehensive analysis of the factors influencing residents' perceptions in long-term care environments.
Furthermore, while the study collected both qualitative and quantitative data using the GDS and PSQI, the predominant reliance on qualitative data hampers its ability to perform robust quantitative comparisons.This limitation restricts the statistical power of the study, hindering the establishment of statistically significant conclusions.Future research endeavors should aim to strike a balance between qualitative and quantitative methodologies to provide a more comprehensive understanding of the studied phenomena.In sum, the limitations identified in this study underscore the necessity for cautious interpretation and highlight areas for improvement in future research efforts.
Finally, this study lacks a comprehensive analysis regarding the environmental factors affecting older adults in LTCUs.While measurements of illumination, noise, temperature, and humidity were conducted, further analysis to determine the optimal environmental conditions for older adults was not included.Additionally, aligning these findings with the daily schedule and activities of older adults was not thoroughly explored.Future research should integrate such analyses to better understand the relationship between environmental factors and the well-being of older adults in long-term care settings, ultimately facilitating the creation of more conducive living environments tailored to their needs.

Conclusion
This exploratory study in an LTCU sought to understand older adults' perceptions of their living spaces, focusing on home-like features and privacy, both visual and acoustic.Employing qualitative methods-specifically semistructured interviews-the study found that most participants were satisfied with the home-like atmosphere and privacy of their living environments.However, few participants voiced concerns about the adequacy of privacy conditions.
Most participants scored low on the GDS and PSQI.Sleep was primarily disrupted because of the sensory environment, staff interruptions, and room temperature.Most participants appreciated the social support from attentive staff and surroundings, particularly the privacy of their rooms and the distinct spatial arrangements.Nonetheless, some wished for larger rooms.This study offers valuable perspectives on older adults' perceptions of their living spaces in LTCUs, with implications for enhancing their quality of life in long-term care.

Figure 1 .
Figure 1.Overall floor plan showing the residential units and shared spaces.(Source: KB Goldenlife)

Table 1 .
Demographic information about the participants.

Table 2 .
Interview measurements and questions used.

Table 3 .
ParticipantPsychological factorsApart from environmental factors, participants also mentioned psychological factors influencing their sleep quality.Anxiety, discomfort, and health conditions were highlighted as contributed to poor sleep among participants.

Table 4 .
Primary themes and subthemes for sleep quality and selected quotations.disturbances from various sources such as staff, other residents, and hallway traffic P8 This old lady (my roommate) talks a lot, like she's talking to herself.That's one thing, but everything else is quiet P12 I'm just surprised by someone who is screaming here P13 I have to wake up at dawn when my roommate makes sounds Light Some participants reported disruptions owing to staff conducting nighttime health checks, which involved turning on lights P8 I don't usually nap, so I just try to get a good night's sleep.I don't like lights when I try to sleep.I don't like electric lights I just come in after dinner, close the curtains, turn off all the lights If I press the call and the staff member comes and takes care of me, it's bright again If she takes care of them, then I cannot sleep right away.Because I saw the light, and because of the care, and because the staff came in and out, I think… P5I'm a good sleeper.But it's because of something I care about, I don't sleep well these days.I'm worried about it, and sometimes my blood pressure is a little high P6 I can't sleep.My bed is uncomfortable.I struggle a lot P7 I don't fall asleep right away, it takes me at least an hour or more to fall asleep And once I wake up, I have a hard time sleeping after that P8 I have trouble sleeping when I'm worried and upset about something Otherwise, I just try to go to bed early P10 I got my 3rd COVID-19 vaccine shot and developed glaucoma, so the staff have to come in and out frequently.That interferes with my sleep P13 My roommate defecates a few times at night, and then I get a headache due to the smell.The smell hurts a lot The smell makes me sick That's why I keep saying, I can't stay with my roommate because she smells so bad, although she was a very good person P14 I'm not sleeping well because I'm sick.I'm fine except when it hurts too much Vol:.(1234567890)Scientific Reports | (2024) 14:13243 | https://doi.org/10.1038/s41598-024-62328-0www.nature.com/scientificreports/ of your room and there's nothing.It's just a hallway, and you go down the hallway, and you gather, and you eat.This place is like 12 rooms in a row, and then you go out and it's a hall, and then it's a communal living area, and then the dining room, which is completely separate from the bedrooms.It's all in one place It's all together like that, and it's really nice here The bedroom is 16 m 2 (172 ft 2 ).There's nowhere else that's so organized and engineered for 16 m 2 per room If somebody who can't walk very well sits down, there's a bed, a table, everything around them, so they can just move a little bit and put Continued Vol.:(0123456789) Scientific Reports | (2024) 14:13243 | https://doi.org/10.1038/s41598-024-62328-0 Participants expressed dissatisfaction with certain aspects of the living environment, including the desire for larger rooms, personal space, and improved neighborhood relations P2 What I want to change is… I want you to put a television in the double room.Since we don't have a house, our old guys always lived with television I can't go outside as I want, and I can take the teachers out, so I can't take them home… But I can't be outside all the time to watch TV.

Table 5 .
Primary themes and subthemes for home-like environments and selected quotations.

Table 6 .
Primary themes and subthemes for privacy and selected quotations.